Part 3. Approach to Reading

The student must approach reading differently than the classic “systematic” review of a particular disease entity. Patients rarely arrive to their healthcare provider with a clear diagnosis; hence, the student must become skilled in applying the textbook information to the clinical setting. Everyone retains more when the reading is performed with a purpose. Experience teaches that with reading, there are several crucial questions to consider thinking clinically. They are the following:

1. What is the most likely diagnosis?

2. What should be your next step?

3. What is the most likely mechanism for this process?

4. What are the risk factors for this condition?

5. What are the complications associated with this disease?

6. What is the best therapy?

WHAT IS THE MOST LIKELY DIAGNOSIS?

Establishing the diagnosis was discussed in the previous part. This is a difficult task to give to the medical student; however, it is the basic problem that will confront clinicians for the rest of their careers. One way of attacking this problem is to develop standard “approaches” to common clinical problems. It is helpful to memorize the most common causes of various presentations, such as “the most common cause of mild respiratory distress in a term infant born by cesarean section is retained amniotic fluid (transient tachypnea of the newborn).”

The clinical scenario would entail something such as:

“A 3-hour-old infant is noted to have a mildly increased respiratory rate and slight subcostal retractions. The infant is term, large for gestation age, and was born by repeat cesarean section. The pregnancy was uncomplicated. What is the most likely diagnosis?”

With no other information to go on, the student would note that this baby has respiratory distress. Using the “most common cause” information, the student would guess transient tachypnea of the newborn. If, instead, the gestational age “term” is changed to “preterm at 30 weeks’ gestation,” a phrase can be added, such as:

“The mother did not receive prophylactic steroids prior to birth.”

Now, the student would use the “most common cause of respiratory distress in a pre-term child whose mother did not receive prenatal steroids” is surfactant deficiency (respiratory distress syndrome).

WHAT SHOULD BE YOUR NEXT STEP?

This question in many ways is even more difficult than the most likely diagnosis, because insufficient information may be available to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that the diagnosis is clear, but the subsequent step is the staging of the disease. Finally, the next step may be to treat. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:

Make diagnosis → Stage disease → Treatment based on the stage → Follow response

In particular, the student is accustomed to regurgitating the same information that someone has written about a particular disease but is not skilled at giving the next step. This talent is optimally learned at the bedside, in a supportive environment, with freedom to take educated guesses, and with constructive feedback. The student in assessing a child in the hospital should go through the following thinking process:

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